San Diego Unified School District K-12 Enrollment Form 2008 …



-2286018097500SAN DIEGO UNIFIED SCHOOL DISTRICT2020-21 PreK-Grade 12 ENROLLMENT FORMComplete Sections I-III and sign page 2. Section IV must be completed by office staff. Please print legibly using black or blue ink.6932930127000OFFICE ONLY Student Name: _____________________________________________ Grade:________ Teacher: ____________________________ Room #: _________00OFFICE ONLY Student Name: _____________________________________________ Grade:________ Teacher: ____________________________ Room #: _________For full directions, please refer to Directions for Completing the PreK-12 Enrollment Form available at . OFFICE ONLY 1. Student District ID:OFFICE ONLY 2. Student State ID (SSID):I. STUDENT INFORMATION3. Last name (LEGAL NAME ONLY)FirstMiddleSuffix (Jr, II, III) FORMTEXT ?????4. First Name on teacher rosters:5. Former legal name(s) (optional):6. Birthdate:7. Gender FORMCHECKBOX Female FORMCHECKBOX Male FORMCHECKBOX Nonbinary FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? 8. Is student Hispanic or Latino/a/x? FORMCHECKBOX Yes FORMCHECKBOX No9. Race: (check all boxes that apply) FORMCHECKBOX American Indian or Alaskan Native FORMCHECKBOX Black or African American FORMCHECKBOX Filipino FORMCHECKBOX WhiteAsian/ Indochinese FORMCHECKBOX Asian Indian FORMCHECKBOX Cambodian FORMCHECKBOX Chinese FORMCHECKBOX Hmong FORMCHECKBOX Japanese FORMCHECKBOX Korean FORMCHECKBOX Laotian FORMCHECKBOX Vietnamese FORMCHECKBOX Other AsianPacific Islander FORMCHECKBOX Guamanian FORMCHECKBOX Hawaiian FORMCHECKBOX Samoan FORMCHECKBOX Tahitian FORMCHECKBOX Other Pacific Islander10. Release of Information: Directory-type information may be shared with individuals and organizations authorized to receive this type of information unless it is prohibited by the parent/guardian. See the district’s Facts for Parents for the individuals and organizations, and the student information that may be released. If you do not want the information shared, you must select “Opt Out.” FORMCHECKBOX Opt Out11a. Student email address (optional): FORMTEXT ?????11b. Student phone (optional): ( FORMTEXT ???) FORMTEXT ?????12. Household address: FORMTEXT ????? City, State: FORMTEXT ?????ZIP Code: FORMTEXT ?????13. Primary phone:( )14. Mailing address (if different from household): FORMTEXT ????? City, State: FORMTEXT ?????ZIP Code: FORMTEXT ?????15. City, State, Country of birth: FORMTEXT ?????16. First enrolled in US Preschool:Date: FORMTEXT ?????17a. First enrolled in a CA school (TK-12): Date: FORMTEXT ?????17b. First enrolled in a US school (TK-12): Date: FORMTEXT ?????18. Current Caregiver (check one): FORMCHECKBOX Parent/legal guardian FORMCHECKBOX Other adult (not legal guardian, requires Caregiver Affidavit)19a. Foster Living Situation:Check one if applicable: FORMCHECKBOX Family Home (FFH) FORMCHECKBOX Group Home (FGH) (FFA) FORMCHECKBOX Formal Kinship Care (including NREFM)19b.Temporary/inadequate residence due to financial hardship:Check all that apply: FORMCHECKBOX Living with someone/Doubling up FORMCHECKBOX Unaccompanied Youth FORMCHECKBOX Hotel/motel FORMCHECKBOX Sheltered FORMCHECKBOX Unsheltered FORMCHECKBOX Runaway Youth 20. Other Living Situation: FORMCHECKBOX International Exchange FORMCHECKBOX Residential facility FORMCHECKBOX Hospital (not state hospital) FORMCHECKBOX FORMTEXT ?????21. Complete and include all minors under 18 years of age who live in the same household (siblings and non-siblings), even if not enrolled in San Diego Unified. If additional space is needed, use “Notes” in Section IV on back of form.Full Name: FORMTEXT ?????Birthdate: FORMTEXT ?????School name: FORMTEXT ?????Relationship to student: FORMTEXT ?????Full Name: FORMTEXT ?????Birthdate: FORMTEXT ?????School name: FORMTEXT ?????Relationship to student: FORMTEXT ?????Full Name: FORMTEXT ?????Birthdate: FORMTEXT ?????School name: FORMTEXT ?????Relationship to student: FORMTEXT ?????II. CONTACT INFORMATION Provide at least three contacts—if additional space is needed use “Notes” in Section IV on back of form.22. Parent/Guardian/Contact23. Parent/Guardian/Contact24. Emergency Contacts (other than already listed)Full name FORMTEXT ????? FORMTEXT ?????Full name: FORMTEXT ?????Relationship to student FORMTEXT ????? FORMTEXT ?????Lives with student? FORMCHECKBOX Yes FORMCHECKBOX No If no, provide address here: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No If no, provide address here: FORMTEXT ????? FORMTEXT ?????Relationship to student: FORMTEXT ?????Home phone ( FORMTEXT ???) FORMTEXT ?????Work phone ( FORMTEXT ???) FORMTEXT ?????Cell Phone ( FORMTEXT ???) FORMTEXT ?????Home phone( FORMTEXT ???) FORMTEXT ?????( FORMTEXT ???) FORMTEXT ?????Email address: FORMTEXT ?????Work phone( FORMTEXT ???) FORMTEXT ?????( FORMTEXT ???) FORMTEXT ?????Primary language: FORMTEXT ?????Cell phone( FORMTEXT ???) FORMTEXT ?????( FORMTEXT ???) FORMTEXT ????? FORMCHECKBOX Interpreter requiredEmail address FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX OK to release student Employer FORMTEXT ????? FORMTEXT ?????Military (check all that apply) FORMCHECKBOX Active Duty FORMCHECKBOX DOD Employee FORMCHECKBOX ReservesNational Guard FORMCHECKBOX Full Time FORMCHECKBOX Part Time FORMCHECKBOX Active Duty FORMCHECKBOX DOD Employee FORMCHECKBOX ReservesNational Guard FORMCHECKBOX Full Time FORMCHECKBOX Part TimeFull name: FORMTEXT ?????Relationship to student: FORMTEXT ?????Primary language FORMTEXT ????? FORMTEXT ?????Home phone ( FORMTEXT ???) FORMTEXT ?????Education level(select one) FORMCHECKBOX Not a High School Graduate FORMCHECKBOX High School Graduate FORMCHECKBOX Some College/AA Degree FORMCHECKBOX College Graduate FORMCHECKBOX Graduate School/Post-Graduate FORMCHECKBOX Decline to state FORMCHECKBOX Not a High School Graduate FORMCHECKBOX High School Graduate FORMCHECKBOX Some College/AA Degree FORMCHECKBOX College Graduate FORMCHECKBOX Graduate School/Post-Graduate FORMCHECKBOX Decline to stateWork phone ( FORMTEXT ???) FORMTEXT ?????Cell Phone ( FORMTEXT ???) FORMTEXT ?????Email address: FORMTEXT ?????Primary language: FORMTEXT ????? FORMCHECKBOX Interpreter requiredAdditional information Report card & Progress report provided FORMCHECKBOX Interpreter required FORMCHECKBOX Access to student info online FORMCHECKBOX Report card FORMCHECKBOX Progress report FORMCHECKBOX Interpreter required FORMCHECKBOX Access to student info online FORMCHECKBOX OK to release student SIGNATURE REQUIRED ON REVERSEIII. Questions for Parent/GuardianThe following questions provide important information for the school staff. Parents must review the following questions. Check “Yes” or “No” for each question where appropriate. Questions 28, 30 & 31 require that you check “Opt Out” or leave blank if you agree to your student’s participation.25a. Has your student ever received Special Education services?25b. Does your student have a 504 Plan? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No 26. Has one of the parents/guardians engaged in migrant work (moved and worked seasonally in jobs related to agriculture, lumber or fishery) in the past three years? FORMCHECKBOX Yes FORMCHECKBOX No 27. Name, city, and state/country of last school attended: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last grade level completed: FORMTEXT ????? 28. (For students in Grades 7, 9, & 11) The district would like your student to participate in the California Healthy Kids Survey (CHKS). The survey is anonymous and confidential. If you do not want your student to participate, you must select “Opt Out.” FORMCHECKBOX Opt Out29. (High school students only) Has your student ever played interscholastic athletics? FORMCHECKBOX Yes FORMCHECKBOX No30. (Grade 12 only) The district is required to submit a Cal Grant high school GPA to the California Student Aid Commission (CSAC) for all graduating seniors unless the parent opts out of the submission process.? The GPA will be submitted electronically by October 1 of each year unless you select “Opt Out,” or submit an Opt Out form. FORMCHECKBOX Opt Out31. (High school only) Federal law requires release of student information to military recruiters. If you do NOT want this information released for your student, you must select “Opt Out.”? FORMCHECKBOX Opt Out32. (High school only) Parents may authorize their student’s school to release educational information including: a. Transcripts, Letters of Recommendation, Financial Aid Forms, Report Cards, and Class Ranking Status including UC ELC data b. Disciplinary RecordsBy checking “Yes” I give permission to State/Federal Financial Aid Programs/Scholarship Programs/Private Schools/University/College personnel and their authorized agents to access my student’s educational records. Special Education and medical information will not be released without additional consent (a separate form will need to be submitted). FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No33. LEA Medi-Cal Billing Program (Facts for Parents: Section F-Notice Regarding the District’s participation in the LEA Medi-Cal Billing Program) FORMCHECKBOX I consent to the release of my child’s related health records for Medi-Cal billing purposes FORMCHECKBOX I do not consent to the release of my child’s related health records for Medi-Cal billing purposesThe information provided in Sections I-III is true to the best of my knowledge. FORMTEXT ????? FORMTEXT ?????Parent/Guardian/Contact signature (required)Date-198120-31432500IV. DISTRICT ADMINISTRATIVE INFORMATION – FOR OFFICE USE ONLY34. Address verification document:36. Neighborhood school: ______________________________38. District of residence: ___________________________ Interdistrict Attendance Permit InterSELPA agreement40. Immunization status: Complete Incomplete Conditional Exempt - District Nurse Approval Required 35. Date address verified: / / 37. Birth verification documents: Birth certificate Affidavit Church records Passport School records Unverified 39. Boundary exception for non-resident student__ 41a. (K only) Dental Exam? Yes No 41b. (K only) Physical Exam? Yes NoENTRY INFORMATION42. Previously enrolled in San Diego Unified? Yes* No *If Yes: Last year enrolled_______________ School______________________________________Grade___________43. Entry date: ______ / ______ / _____44. Entry reason (check one): Enter from within San Diego Unified Enter from Out of District Initial Enrollment-Preschool Enter from Out of State Initial Enrollment TK-12 Preschool Enroll-Not Initial Enter from Charter School within San Diego Unified45. For students new to San Diego Unified entering from within California:Student State ID (SSID) (if known): ______________________Previous CA district: ___________________________________Previous CA school name: ______________________________ 46. For students new to San Diego Unified entering from outside of California: Previous school name: _________________________________________________ City, State/Country: ___________________________________________________ NOTES/Additional Information/Legal BindingsSAN DIEGO UNIFIED SCHOOL DISTRICT 2020-21 PreK–Grade 12 ENROLLMENT FORM (rev 03.02.2020) ................
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